Although not every human culture would recognize psychological terms as we use them in North America and Europe, every culture has ways of talking about how individuals feel, and every culture has terms that describe extreme and abnormal versions of these feelings. Cultural concepts of distress are those culturally-specific ways that people from within a given group express their psychological distress. For example, Cambodians talk about a “khyal attack” as an experience whereby “wind” that flows naturally through the body (akin to chi in Chinese medicine) is blocked from exiting, causing problems that Western psychologists would call symptoms of panic attack (if you’re at all curious, you really should visit the website dedicated to explaining khyal attack).

A couple of colleagues and I recently published a review in Social Science and Medicine of the symptoms that are included in the various ways that different cultures think about the emotional distress following trauma. Our review included 55 studies and identified 116 different cultural concepts of distress. We categorized these concepts based on their symptoms (using hierarchical cluster analysis), and found that the 116 concepts could be described in four basic categories: (1) somatic dysphoria, which largely concerned bodily complaints; (2) behavioral disturbances, “odd” behavior (relative to cultural norms), (3) anxious dysphoria, which as its name implies included lots of anxiety; and (4) depression, which was surprisingly similar to depression as it appears in North American and European medicine. Notably, none of these groups of concepts looked like the psychological disorder that most mental health professionals in North America and Europe think of when they think about trauma — posttraumatic stress disorder, or PTSD.

Of course there are all sorts of limitations to our review, and some would argue that the way we categorized cultural concepts of distress using symptoms alone misses the point of the diversity of these concepts globally (which is broader concerning explanations for distress than it is concerning symptoms). Others would argue that PTSD is actually somewhere in the mix of concepts we reviewed. I’d like to think our review is a starting point for discussion of these issues, rather than a definitive answer to any of these questions.

You can find a link to the publication in Social Science and Medicine here.

The latest issue of Psychological Assessment includes an article by University of Pennsylvania postdoctoral research fellow (and soon to be Manhattan College Assistant Professor) Nuwan Jayawickreme that provides support for the use of locally developed distress measures in post-disaster settings that are beyond the cultural boundaries of Western psychology’s usually realm. Are Culturally Specific Measures of Trauma-Related Anxiety and Depression Needed? The Case of Sri Lanka provides empirical evidence suggesting that once locally-developed measures of posttraumatic distress are administered, administering measures of PTSD and depression (as defined by DSM-IV) does not provide any more useful information vis-a-vis an individual’s impairment of day-to-day functioning.

Developing psychological distress measures in non-Western disaster zones has been on the agenda of many in the disaster mental health field for over a decade now. The essential problem is that conceptualizations of mental health problems and the way that different people from different cultures express their distress vary widely. So, when mental health professionals need to assess individuals to see if they need treatment, they need a measure (questionnaire, survey, or some other standard measurement tool) that is sensitive to that population. How are such tools to be developed? Jayawickreme explains:

Identifying such idioms first need to use ethnographic methods to understand how the social world interacts with the individual’s physical and psychological processes. Such ethnographic studies usually involve an in-depth examination of a specific culture’s conceptualization of a particular experience. Once the concepts and the idioms used by the community in question have been identified, questionnaires or inventories can be developed to assess these concepts, which are then validated using iterative statistical and field testing methods

And that’s what he did. And then he administered this measure, called the Penn/RESIST/Peradeniya War Problems Questionnaire (PRP-WPQ), the PTSD Symptom Scale (or PSS, a standard PTSD scale developed by trauma treatment luminary — and Jayawickreme advisor — Edna Foa) and the Beck Depression Inventory (the BDI, a standard measure of depression) to 197 Tamil Sri Lankans living in the war torn northern and eastern parts of the island. And then he looked at the incremental ability of the PTSD Symptom Scale and the Beck Depression Inventory to predict a measure of functional impairment.

Jayawickreme’s regression analysis showed what some of us have been talking about (and even publishing empirical results on) for a while now: Using measures of psychological distress with local populations that incorporate terms that they can understand is better at getting at the functional impairment due to this distress than using DSM-IV based measures.

The current findings provide support for the notion that sensitive measurement of psychopathology in non-Western, war affected populations may require the development of instruments that incorporate local idioms of distress. As noted earlier, there are limited resources available for providers of psychosocial aid in non-Western, war-affected countries. Given the considerable needs of such populations, it may seem inappropriate to engage in what appears to be a costly and complicated process to develop measures incorporating local idioms of distress. The current results do indicate that the PSS and the BDI predict functional impairment to a substantial degree. However, the current results also suggest that measures incorporating idioms of distress may improve our ability over and above the established measures to identify those who are functionally impaired because of mental illness and who therefore need assistance.

The September 2011 issue of Transcultural Psychiatry is out, and it includes an article by myself and some colleagues based on some work we did with Darfur refugees a few years ago. Publication lag times as they are (a colleague this morning compared them to the aging of fine wines), by the time an article is finally comes out in print the author’s ideas about what he/she sees as the “take-home” message may have shifted slightly. So here’s my chance to provide the 2011 take-home to a study written in 2009.

We took an emic-etic integrated approach, identifying local constructs and then measuring both Western and local distress constructs within the same population in order to compare associations between two sets of symptoms of theoretically related concepts.

This means we (1) talked to a lot of refugees to hear how they defined their problems (including symptoms of psychological distress) and then followed-up with traditional healers to hear how they categorized these symptoms into larger psychological problems (“idioms of distress” for you budding transcultural psychiatrists out there); and (2) conducted a survey that included these problems and Western concepts (PTSD, depression) to measure how the Darfur problems and Western concepts were differentially associated with trauma experiences, loss, and impairment in daily living. The two Darfur problem sets were labeled hozun — “deep sadness” — and majnun — “madness.”

I’ll let you read the article to get the details, but suffice it to say that these sets of disorders — hozun and majnun on the one hand and PTSD and depression on the other — shared many symptoms in common. Related to this, they were associated with traumatic events and functional impairment at comparable levels — in other words, one could “predict” functional impairment using hozun and PTSD and get similar effect sizes (with slight favor for the locally-defined problems).

One might think that if a measure of PTSD is as good as measure developed for a local distress idiom in predicting a third variable you are interested in, then there is really no reason to develop the local measure. In the article we emphasized that the response to this argument had to do with respecting local populations and avoiding psychiatric colonialism. Now although I agree with those ideals, I would emphasize another point we made (but did not emphasize): Just because many of the symptoms of two different disorders from the Western psychiatric canon (here PTSD and depression) overlap with two different disorders from a different medical tradition (here hozun and majnun), it is how the symptoms are arranged in their respective traditions that define the disorders. From the article:

although they accounted for similar variance in Study 2 as a set of items, these symptoms were categorized by traditional healers into sets that were different that the sets of symptoms in PTSD and depression. This, then, suggests that it would be incorrect to argue that PTSD and depression are culturally valid constructs in settings in which respondents report variance on PTSD and depression simply because of that variance.

In other words, just because non-Western participants in a study answer that they have problems (or do not have problems) that fit into Western DSM-IV ideas of psychiatric disorder does not mean that Western DSM-IV ideas of psychiatric disorders are valid definitions of their problems. Figuring out what are valid definitions for their problems is not, at its most basic, a statistical task, but rather a theoretical one. You have to talk to the people who know the theory, not just the people who have the problems.

Whenever I teach response style — the tendency people have to express themselves using a consistent and limited range of expressive behavior — I talk about my grandmother. Lavern Rasmussen was a small-town Minnesotan with deep roots in Swedish and Danish communities. When my family would call her to check in, she would let us know that things were great by saying things were “not bad” and that things were not going so well by saying, “Oh, well, you know…” In teaching my students in New York, I ask them to translate Grandma’s responses into those of a randomly selected individual from the 8 million in our fair city, and when they do this (usually both positive and negative responses involve language unsuitable for printing in these pages), it becomes obvious that there are cultural differences within the U.S. as to how people respond to questions.

Why do psychologists care about this? Many of us use responses to questionnaires as our representation of people’s emotions, and if a certain group of people are responding on the low end of the scale and another group on the high end and we want to compare them, we need to know the characteristics of each group’s response style in order to tell if they are in fact having different reactions or not. And now I have a study to help me explain Grandma’s response style.

First, credit where credit is due: it was Andrew Ryder of Concordia University that passed this study along, in a class on statistical models in emotion research. The class is part of McGill University’s Summer Program in Social and Cultural Psychiatry, which I am attending through the month of May. (In my humble opinion McGill has the best collection of thinkers on how culture shapes emotions, cognitions, and perhaps most importantly the practice of mental health.) Professor Ryder was discussing his own work on differences in behavior between depressed European-origin Canadians and depressed Chinese, and noted that each group had particular norms for emotional expression of happiness — for example, when to smile, what to smile at, even how to smile. Note here that emotion researchers make a distinction between emotions — the actual feelings — and emotion behaviors — the things you do to show the feelings.

When emotion researchers talk about happiness behavior, they almost always mention that U.S. Americans are really into expressing their happiness, as did Prof. Ryder. But, he added, there is significant variability in the expression of happiness in U.S. that is connected to cultural identity, even cultural identity four- or five-generations removed. And this brings us to Scandanavian Americans — those U.S. residents with ancestors from Sweden, Denmark, Norway and Finland. It turns out that they are different.

In Variation among European Americans in emotional facial expression, Jeanne Tsai and Yulia Chenstova-Dutton compared facial expressions among “Scandinavian Americans” and “Irish Americans” after inducing six emotions (happiness, pride, love, anger, disgust, and sadness) through a somewhat convoluted (if ethical) “relived emotion task.” And what did they find? What any Swedish grandmother will tell you: the Irish are more emotional. Or, to look at the other side, as Prof. Ryder did, “You have to control for Scandinavian Americans’ ‘Scandinavianness’ to get them to look like the rest of Americans.”

I don’t want to get too emotional here, but I kind of think my Scandinavianness is not too bad — although I don’t want to make a big deal about it.

Before going into the article itself, a couple of terms. First, epigenetics.Genetics is the study of how traits are passed on from one generation to the next via genes (in DNA) and epi is a prefix indicating essentially “related to but not of” (from the Greek preposition meaning on, around, above, nearby, outer, etc.), so epigenetics concerns those phenomena that result in traits being passed from one generation to the next that are not directly due to genetic material alone. In other words, those things that affect the phenotype without affecting the genotype (for those of you in High School biology). Epigenetics has been a hot field in mental health research for a few years now, particularly among those who want to explain how childhood adversity might influence the ability to tolerate stress later in life.

Second term, DNAmethylation (I’ll admit I had to look this one up). Methylation is the addition of a methyl group — a group of chemical characterized by CH3 (for those of you in High School Chemistry) — to DNA. The addition of a methyl group to DNA is critical to development, and the amount and location influences how a gene will be expressed. Importantly, (1) methylation happens because of phenomena external to the gene — i.e., it is epigenetic — and (2) it can be passed on to later generations.

Okay, the article. A group of researchers in Switzerland set up an animal model of transgenerational transmission of the impact of early life stress using mice. (Animal models are useful to mental health research because they allow researchers to manipulate aspects of research design.) How did the Swiss operationalize early life stress in this model?

Essentially, they stressed out the new mice mothers (“dams”) and took them away from their mice children (“litters”) at irregular intervals (“MSUS”) throughout the first two weeks following birth. They also left a separate group of dams and litters alone. They observed these two groups of mice, and found what others have found, that among the “treated group” (i.e., the ones with unpredictably separated and stressed mothers) there were fewer of the behaviors associated with healthy mouse development — arched-back nursing, regular licking and grooming, and time hanging out on the nest — when the moms were in contact with their litters. In addition, when the little mice grew up, males in the treated group spent more time floating passively in a “forced swim” test (dropping mice in water and seeing how fast they swim, essentially), spent more time immobile in a “tail suspension” test (holding mice by their tails), and ate less sugar (a “sucrose consumption test”) than mice in the nontreated group. These traits were seen as “depressive-like” behavior. Notably, females were not different from all the mice who were raised without the unpredictable and stressed mothering.

Once the two groups of litters were old enough to breed, the researchers bred the males of the stressed group with a new set of female mice (who grew up normally) quickly separated them from their litters and female partners so as not to influence the behavior of their children once born, did not stress the mothers, and then observed the behaviors of their offspring — i.e., the second generation. Then they did the same thing with the next — the third — generation as well. With some slight variability, results from the first generation were replicated in both second and third generations, suggesting that not only is there an effect of early life maternal child-rearing practices that persists across (mice) generations, but also that this effect is independent of how subsequent mothers rear their litters, and thus it must be carried by the father.

So how is this done? What is the mechanism of transmission? Combining their findings and the knowledge about epigenetics, our Swiss friends thought that maternal separation combined with unpredictable maternal stress might be altering gene expression through DNA methylation in sperm cells. So:

To determine whether DNA methylation was altered by early stress in the male germline, we examined its level in the promoter of the several candidate genes in sperm from F1 MSUS males. (p. 412)

The “several candidate genes” here were genes that are associated with the regulation of depressive-like behavior. What did they find?

Methylation of the CpG island surrounding the transcription initiation site of MeCP2 and CB1 genes was increased in F1 MSUS sperm. In contrast, for the CRFR2 gene, methylation in a stretch of the CpG island located 5′ of the transcription initiation site was decreased. Methylation was not changed in target regions of the 5-HT1A or MAOA gene. (p. 413)

What did they find? Essentially, DNA methylation was different for some of the genes in the group that had been subjected to maternal separation combined with unpredictable maternal stress than in the group that had been allowed to lead a normal mouse childhood.

So early maternal separation and distress can have effects at the epigenetic level that are carried through paternal lines to subsequent offspring. This is important news for developmental psychologists studying depression and other disorders, and should not be underestimated. That someone has figured out how care-taking behavior affects gene expression and can be carried across generations to me is simply phenomenal. But what does it all mean for trauma studies? I mentioned above this article was advertised as important for trauma studies, but the term trauma never comes up once in the manuscript — rather, the authors focus on “depression-like” behavior. This may be relevant to trauma studies — most people who develop PTSD also develop depressive disorders as well — but the research doesn’t show that somehow PTSD is passed along intergenerationally.

There is another, more subtle critique to be made here as well. The title of the article mentions “early stress” and the authors consistently refer to “chronic and unpredictable stress in early postnatal life” (p. 413) and the like. But I think it’s a mistake to apply these findings to childhood adversity in general, or even neonatal adversity in general. Their model of early stress was particular to one key developmentally crucial relationship: that of an offspring to it’s mother. Although there is good reason to believe that several types of early life adversity can affect one’s proclivity towards depression and other disorders, it does not follow that among these several types that there is one pathway for all, and certainly not that all are best seen as versions of being unpredictably separated from a stressed mother.

In the opinion pages of today’s New York Times the former chairman of psychiatry at Duke and DSM-IV architect Allen Frances writes a passionate plea to the architects of DSM5 not to inadvertently medicalize normal grief. Although I’d made a promise to myself not to keep referencing major press outlets in the blog (because everyone has access to them), this one was too good to pass up. The controversy surrounds the loosening of the criteria for what counts as Major Depressive Disorder (MDD) — what we in mental health call depression. Frances points out that in drafts of the DSM5, if normal grieving (e.g., following the death of a loved one) carries on for more than two weeks, the person grieving would be diagnosable with MDD.

What would this mean? Well, for starters, it would be a windfall for pharmaceutical companies. But no, there’s no real conspiracy here. As Frances explains:

It is not that psychiatrists are in bed with the drug companies, as is often alleged. The proposed change actually grows out of the best of intentions. Researchers point out that, during bereavement, some people develop an enduring case of major depression, and clinicians hope that by identifying such cases early they could reduce the burdens of illness with treatment.

Ah, good intentions… This is a good example of a fine line that comes up often in mental health: that between prevention and over-diagnosis. If the discussion at this year’s American Psychiatric Association meeting is any barometer, this is a major discussion within the various groups designing DSM5. We want to catch mental illness before it becomes full-blown, but we also don’t want to diagnose someone who is sad or troubled for really good reasons and will heal on their own (and maybe even grow out of their grief). Frances:

The bereaved would also lose the benefits that accrue from letting grief take its natural course. What might these be? No one can say exactly. But grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both.

… Humans have developed complicated and culturally determined grieving rituals that no doubt date from at least as far back as the Neanderthal burial pits that were consecrated tens of thousands of years ago. It is essential, not unhealthy, for us to grieve when confronted by the death of someone we love.

I think here Frances misses something (or at least here he misses something — he’s a pretty smart guy, so he probably doesn’t really miss this): taking medication for sadness and stress has become a “culturally determined grieving ritual” for many people in the US. Does that mean that we should accept the medicalization of normal emotions? Of course not. It only means that we should recognize that for many, it has become part of our culture, and turning the tide will take more than rewriting drafts of DSM5.

Those people who dedicate their lives to addressing stressors among displaced populations are frequently faced with an uncomfortable truth: people under a lot of stress sometimes create more problems for themselves. This is a well-observed phenomenon across populations, and is generally known as “stress generation.” As regards trauma work, there is good research to show that the best predictor of future trauma is past trauma. For those of you not well-versed in stress generation, see Constance Hammen’s reflection on her career researching stress generation among depressed individuals in the Journal of Clinical Psychology.

The uncomfortable part of all this is that it can move quickly into “blaming the victim” (particularly as it pertains to trauma). If a combat veteran presents with PTSD and marital conflict due to the irritability and anger that is a part of the PTSD diagnosis, it can be very difficult not to get really frustrated with that vet’s anger and sink into “it’s your own damn fault” despite our initial sympathy. An automobile accident survivor has a higher likelihood of getting into another automobile accident than someone who hasn’t been in an automobile accident because the survivors tend to be extra cautious following their first accident, drive more slowly at the wrong times, get distracted by other drivers, etc.; if these things cause an accident, who is responsible?

When it comes to refugees, blaming the victim may result in less critical aid from the international community and stigma upon resettlement. And yet it’s clear to anyone who’s worked in refugee camps that a stressed population is a difficult population is difficult to work with. Indeed, one of the impetuses behind bringing psychosocial interventions into humanitarian aid is the danger that stressed refugees can pose to aid workers. There are numerous reports of refugees striking out against aid workers for small irregularities in aid distribution or changes in policies. (I should add that their are also striking reports of other refugees coming to the aid of aid workers.)

So how do we reconcile stress generation with our discomfort? Well, first by reminding ourselves that the first order of health provision is not morality. (I’ve harped on that before, and you probably don’t need to read it again here.)

Second, by looking further into stress generation research so we know what we’re talking about. In this literature, folks like Hammen make the distinction between “dependent, interpersonal” stressors and “independent, fateful” stressors. It turns out that research with people with mental health diagnoses have (on average) more stress-dependent events than people without mental health diagnoses, but have the same number of independent events. Dependent events are almost uniformly interpersonal in nature — and therefore plausibly related to how one would act towards others if really stressed. Independent events may be interpersonal, but their core feature is their fateful nature — they are not affected by how someone is acting.

How does the dependent-independent dichotomy map on to the typology of conflict-related stressors proposed in the last entry in this blog? Well, it’s pretty clear that mental health problems aren’t to blame for people being attacked or cause them to end up in unstable resettlement contexts — this is the “direct war exposure potentially traumatic events (PTEs)” category. For “collateral” and “other PTEs” (which, as I think through them may not be as distinguishable as they first seemed), the picture is less clear, and that some of these stressors are related to “being stressed” means that education campaigns surrounding the affects of stress (at the very least) are important. “Social ecological stressors” are clearly set off by displacement, but the breakdown of community institutions may be exacerbated by interpersonal problems. This is why the “social” in “psychosocial intervention” has always struck me as the more important of the two traditions. “Daily hassles” are likewise split between those problems that are outside of the control of the individual (e.g., a military checkpoint) and those that are exacerbated (unemotional reactions to hearing of abuse of loved ones). So perhaps the dependent-independent dichotomy is a second axis that runs through the typology proposed a few days ago. (Again, comments encouraged here.)

Important to remember through all of this is that all of these stressors are precipitated by an initial event — the event that was the cause of displacement. It would be difficult to argue that displacement events were dependent stressors. And yet many subsequent stressors, be they mild or traumatic, are dependent to some degree. In order to address these, humanitarian aid workers must remember the latter, and the former; they are equally important.